|This form does not replace the need to report suspected adverse events following immunisation via the Yellow Card scheme.|
If you have already reported using the Yellow Card system and have received a link to this proforma to provide additional information, then please proceed below.
If you have not yet reported to MHRA, then complete this proforma. On the final screen, a summary of your responses will be displayed which you can cut/paste into the online Yellow Card form. You will then be given a MHRA report number which you willl need to enter before final submission.
This system is a collaboration between Public Health England, NHSE and MHRA. PHE is the data owner and controller, and is authorised under Regulation 3 and 7 of the Health Service (Control of Patient Information) Regulations 2002 to collect the data (including personal identifiables [PII]) requested below. By entering your details as Reporter, you consent to further contact by PHE/MHRA/NHS representatives if required.